Gestational Diabetes

My trusty Dexcom sensor

You may remember that I started myself on insulin back in July, before I'd even seen my OB, because my morning blood sugars were running high.  My sugars were weird from the very beginning, so I've intermittently been wearing a continuous glucose sensor to make sure I wasn't missing anything, and was lucky enough for the first two trimesters to be able to eat just about anything I wanted to.  But at 24 or so weeks that changed and I became very restricted with my diet. Last week I finally switched my insulin from NPH to the newer, longer acting Levemir - and wow has it made a difference.  I'm constantly wearing my sensor now, and am amazed at how much better my blood sugars look, and so happy that I've been able to add some things (like fruit) back into my diet.

Dealing with this for the past few months has given me such a different perspective on managing my patients with gestational diabetes, both from a diet and medication standpoint, as well as from a personal interaction standpoint.  We've been taught that the best way to manage diet is to follow what's known as the Jovanovic diet, and for many women that does work best. But I have discovered that my sugars do much better with following the similar 3 meals and 3 snacks a day regimen as is prescribed with the diet, but with less carbs at lunch and supper.  I have a better idea of when NPH insulin works, and when Levemir is better.  And I know firsthand what it's like to look a donut in the face and think, "Is this food worth the health of my baby?"

Damn, it's hard to follow this diet!  Intellectually I knew that, but it is so much different to live it.  And I'm lucky enough to really understand the diet and insulin before getting the diagnosis (or should I say, giving myself the diagnosis), so I didn't need lots of training. I have access to things like a continuous sensor (I now can't imagine having insulin requiring diabetes without having a sensor!), and other endocrinologists and diabetes educators to bounce ideas off as I've tried to manage my sugars the past few weeks.  I think it's much easier for me than it is the average patient, and yet it's still frustrating.  I hope that this experience makes it easier for me to help my patients; I know that it has already made it easier for my patients to accept my recommendations once I share with them that I also have GDM, and that I'm also taking insulin.

I haven't eaten Fruity Pebbles in years, and yet that's all I think about when someone asks me what I want to eat.  Fruity Pebbles, PopTarts, Oreos, donuts, Peeps, milkshakes (I had one almost every day of my 3rd trimester with Finn), bagels, pasta and pizza all dominate my daydreams.  I cannot wait to be able to eat whatever I want to once this baby boy is finally born.

But on the bright side - I've eaten so much healthier this pregnancy than I did with Finn. I have a leafy green salad for lunch every day, I'm eating tons of veggies and a reasonable amount of fruit.  And I've actually lost two pounds in the past month.  I'm pretty sure that while I started out this pregnancy 10 pounds heavier than I did my last pregnancy, I'm now just a few pounds over where I was at this point with Finn.  While my stomach has gotten bigger, the rest of me has not, and that has been really lovely.

Is it wrong that one of the main reasons I hope I can exclusively breastfeed again this time is so that I can eat whatever I want and still lose weight?

Almost 16 Weeks

"Baby Chimichanga in Finn's tummy!"

I'm pretty sure that June and July were the longest months ever recorded in human history.  And now here it is, almost the end of August and I'm almost 16 weeks pregnant.  (If you go by my transfer date, I'll be 16 weeks Tuesday, if you go by the due date my RE gave me after my first ultrasound, I'm 16 weeks tomorrow.)  My nausea is finally easing up - last week I was able to cut down and then completely eliminate Zofran, and this week, I was eating almost normally.  Tomorrow I'm going to try going back to salads for lunch again, though I'm a little worried about what that might do to my blood sugar.  When I was feeling my worst, I was shocked to discover that my after meal sugars were only high after eating less carbs instead of more.  Even this past week, when I switched up the croissant on my turkey melt for the healthier option of whole wheat, my sugar spiked.  It makes no sense to me or my partners at work, but thus far they've prescribed a high carb diet for me.  Which is lovely, but it feels so unhealthy.  I'm ready to start feeding this baby healthy foods!

Tuesday is my anatomy scan.  Over the past few weeks, I've revisited the time immediately before and after my anatomy scan with Finn.  It's such a pivotal moment in a pregnancy, at least it is for me.  The moment when a few of the maybes and possiblies become realities.  The moment when the list of potential names is cut in half, when I know if I should pick up that cute pink onesie in the store, or go with the blue one, when I can start using he or she instead of he/she or it.  When I can tell Finn, "your baby brother" or "your baby sister" instead of "your baby brother or your baby sister" (which usually results in me being corrected by Finn, "baby SISTER.")

I'm not going to lie.  I'm going to be a little disappointed if it's another boy.  Not devastated disappointed (as I have a suspicion I might be a better boy mommy than girl mommy - and boys are pretty darn great), but disappointed nonetheless.  So these last few days - hours - of not knowing are a little bittersweet.  If I find out that Chimi is a boy, I'll feel a pang that will quickly pass, but it's almost nice to be where I am right now, not knowing.

Almost nice.  But not nice enough to decide to wait until the baby is born to find out!  I have been talked into a gender reveal party at work, though.  I was already feeling a little disappointed that almost everyone will find out via text, call or blog, and almost no one will hear the news in person, so I'm glad that I got talked in to this!  A drug rep friend is going to have a cake made for us at work - I'll call her after the scan and let her know the gender, and then she'll bring the cake by for lunch on Wednesday.  That means I'll have to keep the secret for a little while longer at work (which will be hard, I know they'll be pestering me!) and I'm going to delay my announcement on Fac.ebook by a day.  I still haven't made this pregnancy FB public, yet, as I'd decided to hold off until I could share the gender at the same time. Another day won't make a difference, I don't suppose.

And now I need to get back to studying.  Blergh.

Super Sweet

Sleep more appealing than cookies?

I finally have my new OB appointment scheduled for August 7...by then I'll be over 13 weeks.  My first trimester screening is this coming Wednesday, though.  I'm hoping the MFM will let me do the Materniti21 test, both for reassurance that Chimi is trisomy free, as well as for the added benefit of knowing the gender a few weeks early.

The entire OB/Gyn group that delivered Finn stopped the OB part of their practice about a year ago.  There are only two other groups in town, and thanks to my health insurance, I'm stuck going to either one of those groups.  The group I decided on was basically by exclusion - I really dislike several of the doctors in the other group, and only mildly dislike a few of the doctors in the one I went with.  Now I dislike the group I decided on even more, thanks to the jerks they were around scheduling my first appointment.

I see a lot of patients from both groups (mostly with diabetes in pregnancy) and I know how they do things.  So I know that despite the fact that I had some high sugars after meals while pregnant with Finn (even after passing the glucose tolerance test with flying colors) and the fact that I had a baby who weighed 9lb13oz, they would not have had me checked for gestational diabetes yet.

Nevertheless, I've been monitoring my sugars since I got my first positive pregnancy test.  They started off fine.  But then about 3 weeks ago, the fasting sugars started to increase about the goal of less than 90.  So I started myself on metformin, and then increased the dose up to the max dose of 2000mg a day.  But still my fastings were high, in fact, Friday morning my fasting was 104 - WAY too high in my opinion.  Surprisingly, my post-meal sugars are excellent; even eating things like mac and cheese and giant baked potatoes, my post-meal sugars are all well within the normal range.

So I started myself on insulin on Friday night - 12 units of NPH.  And this morning my blood sugar was perfect.  Finally.  Thank goodness.

I'm so annoyed to be on insulin - my pregnancy is now officially high risk (though I guess it already was based on my age).  I'll have a lot more monitoring later in pregnancy, which is going to be a hassle with my work schedule.

But more than that, I'm relieved.  Sometime in the past week or so, the baby's pancreas has started making insulin, which means that the baby is going to be affected by my high sugars (my sugar passes into the baby's bloodstream, and the baby's pancreas has to work harder than it should to make more insulin - this increases the risk of low sugars after delivery, breathing problems, feeding problems, as well as increases the risk of obesity and type 2 diabetes for the baby later in life, among other things).  So I'm relieved that I caught it very early and was able to treat it on my own.

Like I mentioned, it's unlikely my OB would have tested me this early, even if I'd already been seen.  What's even scarier is that it's unlikely that my elevated sugars would have even been found with the current testing my OB (and a LOT of other OBs) do, as my sugar would have probably been fine on the one hour screen.  Several years ago the ADA recommended that the current two step testing for gestational diabetes (the one hour post drink test followed by a 3 hour test if that's abnormal) be changed to a standard, two hour test for everyone, that starts with a fasting blood sugar and is followed by a 1 hour and 2 hour check.  If any of those are out of target, you have GDM.  This recommendation was based on the International Diabetes in Pregnancy Study Group paper based on a lot of clinical trials, but primarily the HAPO study, and I was at the IDPSG meeting in 2008 that those recommendations come from.  The argument against this recommendation is that it increases the number of women diagnosed, but if you were one of those women (like myself) who would be missed with a standard screen, wouldn't you want to know? Wouldn't you want the chance to do everything possible to have a healthy child?

Ultimately, I will do anything I can to make sure this baby is healthy.  I'm very thankful that my postmeal sugars are fine right now, as I doubt I could follow the diet.  I am still so sick most days, and am still surviving on carbs with as much protein as I can tolerate (which isn't much).  But as soon as my nausea resolves, I'm following the GDM diet (though if my sugars stay good, I will allow myself cheats here and there!)  The less weight I gain now, the less likely I am to have high sugars later in pregnancy.  I hadn't really planned on watching my calories, and I guess I won't now, but the very act of rationing my carbs will end up limiting my calories somewhat.  And while I'm doing this all for Chimichanga, wouldn't it be lovely if I ended up weighing less after delivery than I did before?

Health Report

I’ve (mostly) recovered from my stomach bug – my insides are still a little off kilter, but that always happens to me when I’ve been sick.  I haven’t eaten much, but I’m eating, and that’s what counts.  At my last OB visit I’d gained 5 pounds in a month.  That after only gaining 8 pounds in the preceding 23 weeks!  My next OB appointment is Tuesday (I’m now at every 2 week visits, can you believe it?) and I’m willing to bet I haven’t gained much this time.  I hope I haven’t lost weight – I really don’t want to get fussed at.

I completely forgot to mention that I passed my glucose tolerance test!  I actually did the test myself at my office.  I hate the current screening method of the one hour test, followed by the three hour test if that’s abnormal.  There are too many missed cases of GDM with that test, and any test that requires you to drink that stuff twice is just wrong.  I’d already decided that I was going to do the two hour test as proposed by the International Association of Diabetes and Pregnancy Study Groups Consensus Panel last year.  I actually attended the 2008 meeting where all the data were presented in and discussed in preparation for this consensus statement, and knew the data well enough to know this test is better, and that’s what I wanted to do.  Lucky for me, the American Diabetes Association adopted those recommendations just last month, so when I took my test results to my OB, I was able to attach the new guidelines to it, so she had no reason to argue with me.  The new guidelines are actually much stricter, making it likely that a few more people will be misdiagnosed as actually having gestational diabetes when they don’t, but it also means that it will be much less likely that people who do have GDM will be missed, which means healthier babies, and that’s what’s important.  (And if someone doesn’t have it, but is told they do, all they’ll have to do is suffer a healthier diet for a few months and that’s not really a big deal.)  So it was the two hour test I passed, and I not only passed it, I rocked it.  Thank goodness!  I have no idea where those high blood sugars came from last year, but I’m glad they’re gone!

Culture Filled Weekend

Yesterday my friend Ali and I drove up into the Foothills for a day at the Highland Games.  There were men in kilts galore, but sadly the young ones were all wearing running tights under their kilts, which tends to ruin the effect (it was COLD!).  The older guys were braver, showing off their knobby knees and goosebumps with pride.  We ate some good food, watched a sheep dog herding some sheep (those dogs are so cool), heard some amazing bagpipes and then two great bands.  The first band we heard was Uncle Hamish and the Hooligans; we loved them enough to buy CDs from the bass player’s mom.  They ended the show with a song that turned into the theme from “Last of the Mohicans” – absolutely wonderful.  Ever since hearing that, I haven’t been able to get the image of Daniel Day-Lewis (Hawkeye) as he says to Cora, “I will find you.  No matter how long it takes, no matter how far, I will find you.”  *delicious shiver*   

Next up was Maidens IV, whose story sounds like something out of a Nora Roberts trilogy, well, quartet.  They’re sisters, 4 out of 9 siblings, who travel around playing Celtic music together.  Mom handles the sound, one of the sister’s husbands runs the CD sales, and between the four of them they play a violin, a viola, a goat-skin drum, keyboards, regular drums, bass and guitar.  It was freezing, but they managed to dance in clogs, sing and play while looking like they were having fun. 

Then tonight I had a different sort of cultural experience; I was invited to a baptism celebration, Ethiopian style.  One of my newer partners at work is from Ethiopia, and his newborn baby boy’s baptism was today.  At the party, we were served traditional Ethiopian food (yummy) and witnessed a traditional Ethiopian coffee bean roasting ceremony.  His priest gave a blessing (in Ethiopian), ending in the Apostle’s Creed, which was instantly recognizable, even though I didn’t understand the language.   I met my partner’s father, who embraced me and kissed me on both cheeks, and was just the nicest man, even though we couldn’t communicate through anything more than smiles.  His mother was much more reserved, but seems so proud of her son and new grandson.  The new baby is just the cutest – chubby cheeks and pouty lips and a round little tummy.  There were tons of children running around, with parents disciplining in English and Ethiopian in between gossiping and lots of laughter. 

As for my blood sugars – I’ve discovered that exercise works wonders.  I went for a long walk today, and since the walk my blood sugars have been perfect, even when eating fruit and chocolate cake at the party today.  It looks like I’ve finally found my incentive to get up and go for a walk every morning!  

A Little Too Sweet

I don’t think I’ve ever mentioned before that one of my areas of interest at work is diabetes in pregnancy.  I didn’t mean for it to happen, but I’m now the doctor who sees just about every pregnant woman in my county if she needs insulin.  A small number of these patients are women who had diabetes before pregnancy, but most of them ended up with gestational diabetes, and when diet alone wasn’t enough to control their sugars they end up being sent to see me.  Sometimes it’s their fault they’re in my office, because they just aren’t doing what they’re supposed to, but many of them really are trying, it’s just not enough.

So of course, when I saw my OB for my first visit, she asked me about my risk factors for diabetes.  My grandmother has diet controlled diabetes, but no one else in my immediate family has any problems, so we decided not to do any early screening on me, instead sticking with the usual plan for a glucose tolerance test at around 26 weeks. 

But then last week I had a horrible lunch.  Someone had brought us barbeque chicken wraps, and the chicken was disgusting, over-cooked and chewy.  I didn’t have time to go out to eat, and so I ended up eating two bites of chicken, then the wrap (with lettuce, sauce and tomatoes without the chicken), two sugar cookies with frosting and 4 snack sized Twizzlers for lunch.  I know, it was a horrible meal, and I didn’t even enjoy it, but I didn’t have anything else to eat.  Not surprisingly, I felt bad a few hours later, so I decided to check my blood sugar... it was high.  A target sugar for someone with gestational diabetes two hours after a meal is 120, but normal is about 105-110.  Mine was 126.  So I started testing – first thing in the morning, and two hours after every meal.  I’ve only had one high after a meal since then, and that was when I was eating out.  All my morning blood sugars have been just a smidgen too high, though, between 88-92.  A target fasting sugar is 90, but normal fastings are in the 60-70s.  That has me worried.  I’m worried about if I’m going to have to start following the gestational diabetic diet (right before the holidays – so unfair!).  I’m worried that getting high blood sugars this early in pregnancy might mean that I have really high blood sugars later in pregnancy.  And I’m really worried that getting high blood sugars this early in pregnancy means that I’m going to get Type 2 diabetes! 

One benefit of being a diabetes specialist is that I have access to things like continuous glucose monitors.  That picture at the top of the page is the receiver for CGM I’m wearing right now.  CMGs are cool little devices; a tiny sensor is inserted just under the skin, and attached to a transmitter.  The sensor constantly measures sugar levels in what’s called the interstitial fluid (the fluid between cells in your skin), and reflects what your blood sugar was about 10-20 minutes earlier.  By wearing one, I can see what my blood sugar is doing all the time, not just when I do a fingerstick blood sugar check.  I’m going to wear it for a week to see what happens to my sugar immediately after eating horrible meals, and what happens when I follow a gestational diabetic diet.  Based on what I’ve seen over the past few days of checking sugars, I have a feeling that I’m going to be able to do ok with just loosely following the diet during the day, and can probably get away with a least some sweets and pastries too.  But the high morning blood sugars are a concern.  I’m going to start doing a bedtime snack every night, to see if that helps (usually that does) and if it doesn’t, I’m going to start metformin.   With my OB’s blessing, of course!  I’ve already decided that if I end up with full blown GDM, I am treating myself.  I know, they say doctors shouldn’t do that, but this is just looking at sugars and dosing insulin.  People with Type 1 diabetes do that on their own all the time, so I think it’s reasonable.  I can just imagine what my chart at my OBs office will say, though.  “Patient refuses referral for GDM education because she says she could teach the class herself if she had to; can already recite diet by heart and has her own glucometer and CGM.”

Quick Primer on Gestational Diabetes aka GDM:

A normal part of pregnancy is that your body doesn't use insulin as well as it usually does, and in response to this increased insulin resistance, your pancreas makes more insulin.  If you already have an increased risk for diabetes, your pancreas might not be able to make enough insulin to cover your body's requirements, and your sugar goes up.  The consequences of high blood sugars (if untreated) are an increased risk of a big baby (with potential trauma to baby and mother during delivery), an increased risk of neonatal hypoglycemia, jaundice and breathing problems, and an increased risk of childhood obesity and type 2 diabetes.  The treatment is diet, followed by insulin of needed, or occasionally an oral agent.  For the mom, the long term concern is that it’s associated with a 50-60% increased risk of type 2 diabetes within 5 years. 

Great.